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Quality Matters: The Painful Truth: Cutting-Edge ED Protocols Blunt Patients' Pain

Welch, Shari J. MD; Fontenot, Sarah Freymann BSN, JD

doi: 10.1097/01.EEM.0000393516.24013.46
Quality Matters


Pain is one of the top reasons patients seek medical care in emergency departments. (Natl Health Stat Report 2010 Sep 23;[28]:1; While there is a general correlation between pain relief and satisfaction, the complexities of ED pain management are still being unraveled. (Acad Emerg Med 1998;5[9]:851.)

Cultural factors, the intensity of the pain, and differing pain scales all confound the relationship between pain and the patient's experience. (Ann Emerg Med 1996;27[4]:436.) Recent studies show that we do not address pain adequately or in a timely way in the ED. (Int J Qual Health Care 2005;17[2]:173.) But new ideas about pain management and satisfaction are emerging.

Pain management in children correlates highly with patient satisfaction, and should be the focus for departments seeing significantly high pediatric volumes. Patients appear to have preferences and expectations for pain management in the ED that can be met easily. (J Emerg Med 2004;26[1]:7; Am J Emerg Med 2000;18[4]:376.) Patients under 54 generally prefer oral analgesia, as do senior citizens, although they prefer intravenous analgesia more than other age groups. The more severe the pain intensity, the more likely the patient will prefer IV medication.

Another study found patients slightly preferred parenteral analgesics over oral, but the study population was exclusively older patients with orthopedic fractures, a subset recognized as frequently being undertreated for pain. In both studies, intramuscular analgesia was the least preferred route of administration for analgesia in the ED. Earlier studies suggested other differences, such as ethnic minorities and women being undertreated. (JAMA 1993;269[12]:1537; Ann Emerg Med 1996;27[4]:485.) Timely treatment of adverse symptoms also deters patients from leaving before being seen by a doctor. In short, an ED should have a well-stocked selection of oral analgesics, and liberally dispense them.

EDs should be able to assess in triage which patients need parenteral medications, and expedite IV placement. When a triage pain assessment is included, patients receive pain medication more reliably and more quickly. (Am J Emerg Med 2008;26[8]:867.) When triage protocols allow nurses to administer pain medication, performance on time to pain management is even better. (Am J Emerg Med 2007;25[7]:791.) Pain treatment need not always involve medications; adjuncts include ice packs, splints, warm blankets, elevating a wounded limb, or topically applying anesthetics. The timeliness of these is critical in the ED, and positively affect patient satisfaction; quality initiatives can facilitate improvements.

In 2007 at the University of Utah, David Fosnocht, MD, led an initiative to have nurses administer PO narcotic analgesics for extremity injuries. They monitored the time to analgesic administration and the rate of administration of analgesics. Before the protocol, time to analgesia was 76 minutes; after, it was 40 minutes. Before the initiative, 45 percent of patients received analgesics while 70 percent did after. This was surprisingly similar to the findings at LDS Hospital across town in Salt Lake City, where a study showed improvements in patient satisfaction surveys as well. (

There is ample reason to address this as your next quality improvement initiative. Protocols that safely allow nurses to begin treating pain at intake are safe. EDs can write protocols for common chief complaints, and the standardized approach will be safer and more efficient.

In 2006, the Institute for Healthcare Improvement's ED Collaborative formed a Protocols and Procedures Workgroup, with participating EDs using standardized order sets in triage. Though never published, most demonstrated improvement on time measures. A recent study of 15,000 patients at Johns Hopkins showed that advanced triage order sets shortened the time to treatment for ED patients. (The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time. Ann Emerg Med 2010 Jun 9.) Several protocols included diagnostic and pain management elements for use at intake, and could be modified for specific EDs. (See tables.)

This is cutting-edge ED operations. The Institute of Medicine has called for health care providers and systems to address quality; would anything address this better than having processes and protocols to address patient's pain as soon as they hit the door?

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Headache Protocol

Exclusions: History of trauma, fever, pregnancy, hypertension, no history of migraines, worst headache of life.

  1. Start IV.
  2. Place patient in darkened room.
  3. Give a cocktail of:
    • 10 mg compazine IV
    • 30 mg Toradol IV
    • 2 Excedrin PO
    • 25 mg Benadryl IV
  4. If headache persists, talk to physician about narcotics.
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Flank Pain Protocol

Exclusions: Pregnancy, hypertension, fever.

  1. Start IV NS at 125 cc/hr.
  2. Give 4 mg Zofran IV or ODT and 30 mg Toradol IV.
  3. If no pain relief, titrate fentanyl to pain.
  4. Send CBC, UA, Chem-7.
  5. Dip urine, and notify physician of results.
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Abdominal Pain Protocol

  1. Start IV NS at 125 cc/hr.
  2. Give 4 mg Zofran IV or ODT.
  3. Titrate fentanyl to pain.
  4. Send CBC, CMP, UA, amylase.
  5. For women, send HCG.
  6. Over 50, send lactate.

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Dr. Welch

Dr. Welch

Ms. Fontenot

Ms. Fontenot

© 2011 Lippincott Williams & Wilkins, Inc.